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For numbered affiliations see
end of article
Correspondence to
Professor Lars Engebretsen,
University of Oslo/
IOC Medical& Scientific
Department, Orthopaedic
Surgery, Kirkeveien 111,
Oslo 0407, Norway;
lars.engebretsen@
medisin.uio.no
Received 17 April 2012
Accepted 23 April 2012
Published Online First
9 June 2012
770
bjsports-2012-091296.indd 1
International Olympic Committee consensus
statement on thermoregulatory and altitude
challenges for high-level athletes
MF Bergeron,1,2 R Bahr,3 P Bärtsch,4 L Bourdon,5 JAL Calbet,6 KH Carlsen,7–9
O Castagna,5 J González-Alonso,10 C Lundby,11 RJ Maughan,12 G Millet,13
M Mountjoy,14–16 S Racinais,17 P Rasmussen,11,18 DG Singh,19–21 AW Subudhi,22
AJ Young,23 T Soligard,24 L Engebretsen24
ABSTRACT
Challenging environmental conditions, including heat
and humidity, cold, and altitude, pose particular risks to
the health of Olympic and other high-level athletes. As a
further commitment to athlete safety, the International
Olympic Committee (IOC) Medical Commission con-
vened a panel of experts to review the scientific evi-
dence base, reach consensus, and underscore practical
safety guidelines and new research priorities regarding
the unique environmental challenges Olympic and other
international-level athletes face. For non-aquatic events,
external thermal load is dependent on ambient tempera-
ture, humidity, wind speed and solar radiation, while
clothing and protective gear can measurably increase
thermal strain and prompt premature fatigue. In swim-
mers, body heat loss is the direct result of convection at
a rate that is proportional to the effective water velocity
around the swimmer and the temperature difference
between the skin and the water. Other cold exposure
and conditions, such as during Alpine skiing, biathlon and
other sliding sports, facilitate body heat transfer to the
environment, potentially leading to hypothermia and/
or frostbite; although metabolic heat production during
these activities usually increases well above the rate of
body heat loss, and protective clothing and limited expo-
sure time in certain events reduces these clinical risks
as well. Most athletic events are held at altitudes that
pose little to no health risks; and training exposures are
typically brief and well-tolerated. While these and other
environment-related threats to performance and safety
can be lessened or averted by implementing a variety
of individual and event preventative measures, more
research and evidence-based guidelines and recommen-
dations are needed. In the mean time, the IOC Medical
Commission and International Sport Federations have
implemented new guidelines and taken additional steps
to mitigate risk even further.
INTRODUCTION
Protecting the health of Olympic athlete is the
highest priority of the International Olympic
Committee (IOC) Medical Commission.1
Emphasising this commitment, an injury surveil-
lance system was established for all team sports
during the 2004 Athens Olympic Games. 2 This
was followed by including individual sports in the
IOC injury surveillance system, beginning with
the 2008 Beijing games. 3 For the 2010 Vancouver
Br J Sports Med 2012;46:770–779. doi:10.1136/bjsports-2012-091296
winter games, the surveillance system was
expanded to include newly sustained illnesses.4
Challenging environmental conditions, includ-
ing heat and humidity, cold, and altitude, pose
particular risks to the health of the athlete. As
athletes must also contend with the unique physi-
cal requirements of their respective sport, univer-
sal safety guidelines do not always sufficiently
address sport-specific injury and other clinical
risks. The interaction between the demands of
the sport and the environmental conditions –
even with seemingly benign environments that
represent limited danger to the general population
under less intense and/or shorter recreational sce-
narios – can present a substantial potential haz-
ard to the health of the Olympic athlete or other
elite athlete who is making an all-out effort for an
extended period of time. For example, exertional
heatstroke has been reported in a marathon run-
ner recovering from a viral syndrome during a race
held in a cool (6.1–9.4°C) but humid (62–99% rela-
tive humidity – RH) environment. 5 Conversely,
during a 21 km event in warm and humid condi-
tions (WBGT 26.0–29.2°C), all runners fi nished
the race without symptoms of exertional heat ill-
ness, despite body core temperature being >39°C
for all of the 18 screened runners. Moreover, 10
of those asymptomatic screened fi nishers had a
body core temperature >40°C, while two reached
41°C.6 Notably, a number of individual factors (eg,
experience, recent health history and status, fit-
ness, acclimatisation, physical and psychological
make-up, nutritional and hydration status and
sweat loss rate) each play a key role in the athlete’s
capacity to adequately adapt to and safely tolerate
new and demanding environments, thus making
it even more challenging to develop and imple-
ment universally effective safety guidelines.
In recognition of these realities, and to further
enhance the IOC Medical Commission’s commit-
ment to athlete safety, a panel of experts convened
in December 2011 to review the scientific evidence
base, reach consensus and underscore practical
safety guidelines and new research priorities for
sports governing bodies, event organisers, medical
support teams, coaches and athletes regarding the
unique environmental challenges Olympic and
other international-level athletes face. Key ques-
tions presented to the panel included the follow-
ing: what are the clinical risks to athletes during
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training and competing in challenging environments? what
are the safe environmental limits for training and competi-
tion? what are the best methods to prepare for and adapt to
environmental challenges? what additional practical preven-
tive measures can be put in place to further minimise health-
related environmental risks? The expert panel systematically
addressed these issues and provides here updated safety and
research recommendations, based on the latest scientific and
clinical evidence.
This consensus article is not intended to be a comprehen-
sive review of environmental challenges and inclusive of all
recommended safety procedures for training and competing in
adverse climates. Rather, the intent is to highlight selected key
environment-related risk factors that continue to challenge
Olympic and other international-level athletes. The other
priority is to re-emphasise and provide additional recommen-
dations to address and minimise those risks associated with
recent and ongoing incidents of environmentally prompted ill-
ness, injury and death in sport.
EFFECTS OF HEAT STRESS ON HEALTH AND PERFORMANCE
OF HIGH-LEVEL ATHLETES
Environmental factors contributing to hyperthermia
External thermal load is dependent on ambient temperature,
humidity, wind speed and solar radiation, and it is generally
estimated by the Wet-Bulb-Globe-Temperature (WBGT) index.
All of these contributing environmental factors are included in
calculating WBGT from the dry (standard thermometer) tem-
perature, the wet-bulb temperature (which indicates the true
capacity of the air to evaporate water according to its RH and
velocity) and the solar radiation (globe temperature). WBGT
indicates the temperature of a saturated immobile air which
would impose the same thermal load as the actual environ-
ment. In hot conditions, conductive heat exchange between
air and skin is usually minimal because the temperature differ-
ence (ie, temperature gradient between the environment and
skin or vice versa) is typically small. Notably, humidity of air
plays a major role in exertional heat illness risk, particularly
in hot conditions. During exercise in the heat, excessive body
heat is primarily lost through evaporation of sweat at the sur-
face of skin. If the humidity is high, the water vapour pres-
sure of air will be high, and consequently sweating is much
less effective in releasing body heat because evaporation is
inhibited.7 Wind speed is also important given that wind can
enhance heat transfer from the skin; moreover, the moving air
readily replaces the skin surface air that has been enriched by
evaporating water with more dry air which encourages fur-
ther sweat evaporation. Certain events with an inherent ele-
vated speed (eg, cycling) will not be affected by high heat and
humidity to the same extent as sports where the body moves
very little or at much lower speeds (eg, athletics, beach vol-
leyball), because the heat release increases with wind flow and
an increase in ambient temperature decreases air density and
aerodynamic resistance.8 9 Lastly, infrared light from the sun
(solar radiation) must also be considered, as this can be a mea-
surable heat source to the surface of the body and often burn
the skin. Sunburn can exacerbate thermal sensation during
exercise and limit thermoregulation, through a locally medi-
ated effect on sweat gland responsiveness and capacity.10
In water, body heat loss is the direct result of convection
between skin and water at a rate determined by the convec-
tive heat transfer coefficient that is proportional to the speed
of water and the temperature difference between the skin
and water; accordingly, it is therefore generally accepted that
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swimmers will not incur hyperthermia in water below 31°C.
However, at all water temperatures, the thermal properties
and design of swimmers’ garments are of tremendous impor-
tance for maintaining thermal balance. Unfortunately, empir-
ical data from the laboratory and field to clarify the specific
effects of practical water temperature ranges on athletes are
limited.
For all non-aquatic events, clothing and protective gear can
measurably increase thermal strain, especially in the heat. The
negative impact is particularly pronounced in certain sports,
such as equestrian or cycling BMX, because of the protec-
tive functional design which can greatly interfere with sweat
evaporation. These effects on thermal strain to athletes must
be taken into consideration in each specific sport, as modifica-
tions to legal protective gear and performance clothing are not
easily implemented.
Physiological challenges during training and competition in a
hot environment
Physical and sport performance across a diverse and wide
range of athletic activity, duration and intensity can be
severely impaired during training and competition in hot envi-
ronments.11 This impairment is manifested by an inability to
maintain strength, power, speed, endurance, and consequently
sport-specific neuromotor skill performance, prompted by
premature fatigue as a result of a complex process involving
multiple physiological systems and mechanisms. Sport train-
ing and competition in hot environments can pose severe chal-
lenges to cardiovascular, thermoregulatory, metabolic, neural
and cognitive function, as well as yield a much greater percep-
tion of effort.12–17 The magnitude of the deleterious effects of
heat stress on performance depends on the sport discipline;
but generally, physiological strain typically increases with
protracted sustained effort as the duration of a training session
or competition progresses. Unsustainable physical activity in
severe heat stress leading to hyperthermic fatigue and exhaus-
tion is characterised by marked dehydration and progressive
concomitant reductions in stroke volume, brain and active
muscle blood flow (secondary to hypotension) and systemic,
muscle and brain oxygen delivery coupled with augmented
brain metabolism, substrate depletion and a progressive
increase in body core and brain temperatures. If unchecked,
this progression can lead to heat exhaustion and, in extreme
cases, life-threatening exertional heatstroke during endurance
and high-intensity activities characteristic of many summer
Olympic sports.
Modifiable factors to minimise risk of hyperthermia and
exertional heat illness
Hydration
Sufficient hydration prior to, during, and in recovery is inte-
gral to athletic performance and safety during training and
competition in the heat. However, because there are large
interpersonal and sport-specific variations in fluid loss,18
it is difficult to provide universal recommendations on
adequate fluid intake. Pre to postexercise changes in body
weight, as well as urine colour and volume, can help athletes
to effectively assess fluid loss through sweating and esti-
mate hydration status.19 Importantly, public health recom-
mendations regarding dietary salt intake (eg, <6 g per day)
may not always apply to elite athletes. Specific monitoring
of daily sodium homeostasis (consumption vs sweat losses)
and deliberately increasing salt intake before, throughout
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and after training and sporting events to maintain sodium
balance and help retain and distribute ingested water, espe-
cially in a thermally stressing environment when sweating
and concomitant losses of electrolytes are extensive, is often
necessary. 20
Acclimatisation
Heat acclimatisation usually refers to the progressive physio-
logical adaptations achieved to improve exercise-heat tolerance
and safety by exercising in natural outdoor hot ambient con-
ditions; whereas heat acclimation refers to an indoor labora-
tory protocol to obtain similar adaptive effects. 21 Importantly,
natural heat acclimatisation is more complete than artificial
acclimation, 22 as it includes other factors beyond physi-
ological heat adaptation, such as learning pacing strategies.
Sufficient sport training in a temperate environment provides
partial desired adaptations, 23 but it does not fully replace heat
acclimatisation. 24
A minimum of 1 week (although, just a few days helps) and
an optimum of 2 weeks of acclimatisation are the typical rec-
ommendations for athletes, before competing in a hotter and/
or more humid environment than they are accustomed to.25
However, individual needs and responses are highly variable,26
and coaches should customise the heat acclimatisation period
and process to each athlete to the extent practical. Several
months before a scheduled hot-weather major event, athletes
should go through an exercise-heat experience similar to what
they expect to encounter, in order to determine their adaptabil-
ity to the heat and to assist in planning their heat acclimatisation
duration and procedure for the weeks immediately preceding the
event. Heat acclimatisation progress can be objectively ascer-
tained by a decrease in sweat sodium concentration, as well as
an increase in sweat rate, a decrease in core body temperature
and a decrease in heart rate in response to a standard exercise
protocol in the heat;27–29 although these changes are not always
measurably realised. When possible, team physicians can also
measure the change in plasma volume before, during and after
heat acclimatisation, to predict the ability of elite athletes to
cope with the heat in competitive situations, and individualise
their preparation accordingly.26 Successful heat acclimatisation
increases work capacity in hot and neutral environments29–32
and reduces exertional heat illness risk.
Warm-up and precooling
Warm-up is fundamental to athletic performance. One of the
main objectives of the warm-up period is to increase muscle
temperature and promote dilation of capillaries to increase
perfusion and oxygen transport to the muscles. When carried
out under hot conditions, warm-up can, however, induce an
undesirable level of body heat storage. Accordingly, subse-
quent physical activity would then begin with a higher body
core temperature that could lead to earlier excessive heat strain
and reduced performance. This underscores the importance of
limiting warm-up intensity and duration during endurance
events in hot conditions and providing enough recovery time
before the start of competition to rehydrate and restore body
core temperature. Precooling the athlete with cold/ice water
immersion, ice vests or other garments/devices before physi-
cal activity, during the active warm-up and between exercise
bouts, in order to reduce baseline body core temperature, has
been shown in some experimental settings to enhance per-
formance, especially with aerobic exercise;33 but data from
actual competitive scenarios are lacking. More recently, ice
slurry ingestion before exercise has been shown to be similarly
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bjsports-2012-091296.indd 3
effective as cold water immersion in enhancing performance
in a laboratory setting. 34 Precooling may thus be warranted
in warm-to-hot weather conditions, especially prior to long-
duration physical exertion or between multiple same-day
bouts of physical activity to reduce heat strain and enhance
performance.
Clothing
Sports clothing should place minimal restrictions on sweat
evaporation, and the naked skin area available for evaporative
heat loss should be maximised. Sport federations should thus
consider potential hot and humid weather conditions when
regulating the competition apparel of their athletes.
Recommendations for sporting organisations and governing
bodies for reducing heat illness risk
Facilities
Event organisers and administrators should provide the best
possible facilities and infrastructure for minimising the heat
strain imposed on athletes throughout competition, as well
as during preparation and recovery times. Such measures
include, but are not restricted to, providing air-conditioned
meeting rooms and locker rooms for athletes and support staff
throughout the event and readily accessible shaded areas to
reduce the overall heat exposure, as well as cooling stations
on or immediately next to the competition site. A comprehen-
sive emergency action plan should be in place with sufficient
trained staff and the capacity for whole-body rapid cooling
and body core temperature monitoring of on-site athletes.
Scheduling
Organisers and sport ruling bodies should allow for resched-
uling of events to a time of day where less heat stress and
exposure would be expected, as well as allow for longer and
more frequent breaks during competition as heat and humid-
ity increase. Time of day can influence athletic performance
in other ways as well – for example, sprint performance is
reportedly better in the late afternoon than in the morning. 35
Certain team sports such as running relays or football may
benefit similarly. Accordingly, many athletes prefer to com-
pete later in the day. Endurance performance in the heat,
however, may benefit from the lower core temperature in the
morning. 36 A passive warm-up effect prompted by a diurnal
increase in body temperature that peaks in the late afternoon
or a warm-to-hot environment itself (but not both concomi-
tantly) can play a role in enhancing muscle capacity and per-
formance. Consequently, for some events, acute exposure to
heat in the morning has the potential to improve the muscle
function and can thus allow sprinters, for example, to reach
peak performance earlier in the day that might otherwise be
more naturally achievable in the late afternoon. 37 This could
assuage concerns of those participating in the qualification
rounds scheduled earlier in the day, and might even represent
an advantage for these athletes; but such a tactic could also
offer more flexibility for the scheduling of a variety of events
by the organiser.
Recommendations for research
While much is known, and myriad protocols have been imple-
mented to improve safety, gaps remain. Accordingly, and rec-
ognising that research and resulting recommendations must
be sport-specific, the panel recommends new research to:
▶ Better characterise the sport- and event-specific thermal and
cardiovascular strain profi les of Olympic and international-
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level athletes competing in the heat using ingestible temper-
ature sensors (‘pills’) and other field-expedient monitoring
devices.
▶ Determine evidence-based, sport-specific safety cut-off
points (using on-site WBGT or other heat index) for restrict-
ing or cancelling competition.
▶ Develop and implement automated safety-monitoring for
recognising and tracking abnormal slowing down of a par-
ticipant and rapid-response procedures.
▶ Improve fluid replacement during endurance competition,
determine optimum prehydration prior to high-intensity
events (eg, 5000 and 10 000 m in athletics), and clarify the
best methods for serving specific sports (eg, team sports)
with effective strategies for optimising hydration.
▶ Determine the effectiveness and the best practice for
warm-up, precooling and periodic cooling during rest peri-
ods for the elite athlete.
Figure 1 Windchill temperature index in Celsius46 and Fahrenheit.47 Frostbite times are for exposed facial skin.
Br J Sports Med 2012;46:770–779. doi:10.1136/bjsports-2012-091296
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▶ Determine the performance- and safety-related acclimati-
sation responses of the elite athlete and the mechanism(s)
behind the large interindividual variability (eg, genetic
basis).
EFFECTS OF COLD EXPOSURE ON HEALTH AND
PERFORMANCE OF HIGH-LEVEL ATHLETES
Effects of a cold environment
Athletes in some Olympic sports are routinely exposed to cold
during training and competition (figure 1). Cold exposure facil-
itates body heat transfer to the environment, potentially lead-
ing to hypothermia and/or frostbite, if sufficient body heat is
lost. That is, despite behavioural and physiological responses
acting to preserve body temperature, core or peripheral skin
temperatures can decline to critical levels, where normal
metabolism and physiological function are compromised and
skin and other tissue damage occurs. 38 Environmental cooling
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power is not only determined by the ambient temperature, but
also by wind, which facilitates convective heat loss, and wet
clothing, which in turn increases evaporative heat loss.8 Water
temperature and current can have significant cooling effects as
well. Moreover, inhalation of cold air, especially during physi-
cal activity, can have additional adverse health effects both for
asthmatic and healthy athletes.
Hypothermia and sports
During the past three winter Olympics, ambient temperatures
have ranged from −5 to +8°C. However, metabolic heat pro-
duction during exercise usually increases well above the rate
of body heat loss in such and even colder air temperatures. 39
For example, during Alpine skiing and other sliding sports,
athletes can be exposed to considerable cold (low-air tempera-
ture and wind). But metabolic heat production during these
activities is very high (6–11 METS, 600–1000 W), and each
run during these events is completed in 3 min or less. Such
brief cold exposures, coupled with such high-metabolic rates,
almost certainly eliminate any risk of hypothermia during
competition. 38 And while some Nordic skiing and biathlon
events require 2 h to complete, metabolic heat production dur-
ing these activities is even higher, often reaching 13–18 METS
(1250–1800 W).40 41 So, despite longer exposures, these very
high-metabolic rates will offset heat loss and prevent athletes
from developing hypothermia during competition in condi-
tions typifying the past three winter Olympics, and probably
even with much more extreme cold conditions.41
The Olympic summer games include a 10 km, open-water
swimming event. Body heat loss during water immersion can
be many times that incurred during exposure to air of the
same temperature, raising concern regarding hypothermia dur-
ing open-water swimming.8 38 39 However, the guidelines of
the governing body for aquatics, Fédération Internationale de
Natation (FINA), specify that the lower limit for water tempera-
ture (measured 1 m below the surface) is 16°C. If water temper-
ature is lower, the event will be cancelled. Thermoregulatory
modelling suggests that male and female open-water swim-
mers will not likely experience dangerous declines in body
temperature in water temperatures of 16°C and higher when
swimming at typical competition speeds.42 However, self-
reports from athletes of perceived functional limitations from
cold water resulting in widespread non-fi nishes at a recent
international open-water championships event (Quebec, 2010),
when the water temperature was at 16°C lower limit, under-
score the need for research examining the appropriateness of
this specific federation cancellation threshold.
A potential arrhythmogenic effect of water is another concern
for swimmers. The combination of cold water exposure, volun-
tary apnoea and face immersion may result in increased sympa-
thetic and parasympathetic activity, possibly causing ventricular
premature beats.43 Accordingly, cold water itself could be a con-
tributing factor to fatal events in open-water swimming.
Frostbite and sports
Frostbite occurs when tissue temperatures fall below 0°C.38 44 45
Notably, wind increases convective heat loss at exposed skin and
increases the risk of frostbite. This is the basis of the commonly
reported ‘windchill’ equivalent temperature (figure 1). In addi-
tion, running and skiing produce wind across the body, adding to
the windchill. When the windchill equivalent temperature falls
below −27°C, frostbite can occur in 30 min or less at exposed
skin.38 During Nordic skiing and biathlon, competitors achieve
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bjsports-2012-091296.indd 5
speeds of 24–27 km/h. At that wind speed, air temperature must
be −20°C or colder to create a risk of frostbite. However, dur-
ing certain Alpine skiing and sliding events, competitors achieve
speeds of 60–100 km/h. At these wind speeds, an air tempera-
ture of only −15°C could create a risk of frostbite. Again, how-
ever, each run is typically completed in 3 min or less; so frostbite
is unlikely to occur at that time. Furthermore, windchill and
the risk of frostbite at these temperatures are only applicable for
exposed skin; so windproof clothing nearly eliminates that risk.
While an individual’s performance may only take a few minutes,
the entire event itself lasts for many hours during which meta-
bolic activity is substantially lower, if not near rest. Frostbite risk
over these prolonged periods, especially for coaches, support
staff and officials who may be standing or sitting in the cold,
should be considered as well (figure 1).
Cold exposure and respiratory problems in athletes
Exercise-induced asthma (EIA) and bronchial hyper-respon-
siveness (BHR) occur in ≥50% of elite cross-country skiers48
and swimmers.49 EIA is thought to be caused by heat loss 50 and
water loss 51 through respiration, while inhaled cold air greatly
enhances the magnitude of exercise-induced bronchoconstric-
tion (EIB) 52 and reduces performance. 53 Cold-facial tempera-
tures increase EIB even if inhaling warm air, 54 suggesting a
parasympathetic nervous reflex. Endurance sports with cold
exposure, including cross-country skiing, Nordic skiing com-
bined, biathlon and speed skating, have a high prevalence of
asthma and BHR. 55 The causative factor is thought to be epi-
thelial damage of respiratory mucosa, as shown in animal stud-
ies. 56 Airway infl ammation, indicated by per cent neutrophils
in induced sputum, is correlated to number of training hours
per week in cross-country skiers and swimmers; 57 while age
and number of competitive years in cross-country skiers has
been associated with level of BHR. 55 Furthermore, participa-
tion in competitive cross-country skiing over a winter season
markedly enhanced airway infl ammation in bronchial biop-
sies in young skiers with and without asthma. 58 In athletes
with positive metacholine BHR compared with negative meta-
choline BHR, sweat excretion, saliva production and tear flow
were markedly reduced, indicating increased parasympathetic
activity. 59 Moreover, increased parasympathetic (vagal) activ-
ity was indicated by protection against EIB by inhaled ipra-
tropium bromide in cross-country runners exercising at cold
temperatures60 and in children with EIB.61 Altogether, these
studies point to respiratory epithelial damage as the primary
contributing factor to respiratory problems in endurance ath-
letes; and this is augmented by cold exposure, thus increasing
airway infl ammation. Moreover, epithelial bronchial culture
cells from asthmatics have been shown to heal more slowly
after scarring compared with healthy individuals. However,
the healing rate was greatly enhanced by adding steroids to
cell culture.62
Cutaneous vasoconstriction prompted by cold water expo-
sure can increase venous return, leading to an increase in blood
pressure and central vascular volume. Reportedly, this can
result in acute pulmonary oedema and hemoptysis in swim-
mers, similar to swimming-induced or immersion-related pul-
monary congestion.63 64
Acclimatisation
The effects of cold acclimatisation in humans are minimal, and
provide little, if any practical advantage in terms of preserving
normal body temperature and preventing cold injury.
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Cold exposure summary
Hypothermia and/or frostbite are very unlikely for rested, fit
elite athletes wearing wind protective clothing and compet-
ing in weather conditions typical of the recent three Winter
Olympics, because high-metabolic rates and brief exposures
limit body heat losses. A very conservative ambient air tem-
perature limit of −15°C during events could be justified to
mitigate frostbite risk. Risk may be higher for athletes during
training due to overtraining or fatigue effects, and atypically
cold temperatures could increase frostbite risk for Alpine ski-
ing and sliding events due to high speeds (wind) achieved.65–67
Although thermoregulatory modelling suggests that hypo-
thermia is unlikely for the athlete swimming in water of 16°C,
field reports indicate that numerous swimmers can suffer from
perceived functional limitations, emphasising the need for
defi nitive field-of-play research.
Increased ventilation during repeated physical training
and competition, with resulting airway infl ammation and
increased parasympathetic activity enhanced by cold expo-
sure, is the probable cause of increased prevalence of asthma
and BHR in cold weather. Inhaled steroids are important for
the healing process and have been shown not to improve
the performance in healthy athletes. The athlete asthma
phenotype is characterised by the presence of BHR, cough
and phlegm. Symptoms occur more frequently after closely
repeated competitions, and exacerbations are frequently
caused by respiratory viral infections. The fi rst symptoms of
asthma often occur when competing with a respiratory tract
infection.
Practical recommendations
For athletes who train and compete in the cold, a number of
key practical guidelines can improve comfort and minimise
exposure-related clinical risk in these conditions. Key recom-
mendations include:
▶ Environmental measures:
▶ Weather conditions (wind, air temperature) should
be measured and recorded before and during outdoor
events. The site where the weather conditions are
measured should be as close as possible to the location
where competitors will be most exposed to the weather
conditions.
▶ Standardised charts to compute the effective wind-
chill temperature from air temperature and wind
speed should be provided to appropriate officials,
and the speed range for competitors in the different
winter events should be printed on that same chart
and used to compute effective windchill temperature
when natural wind speed is less than the speed of the
competitor.
▶ Competitions should be avoided when competitors
would be exposed to combinations of air temperature
and wind speed (including the speed of the competitor)
that achieve an effective windchill temperature colder
than −27°C.
▶ Protection equipment for cold air exposure should be used
during training at low temperatures.
▶ It is important to provide regular medical follow-up of elite
endurance athletes with cold exposure to detect frostbite,
BHR or EIB early.
▶ Efforts for optimal asthma treatment and monitoring
should focus on:
▶ Early anti-infl ammatory treatment (inhaled steroids)
(avoid possible adrenal suppression during exercise).68
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▶ Necessary bronchodilator treatment before exercise
and if needed on regular basis focusing on inhaled anti-
cholinergic treatment. (be aware of possible tolerance
development to regular use of inhaled β2-agonists).69
▶ Other antiasthmatic treatment as indicated.
▶ As some asthma treatments are on the World Anti-Doping
Agency (WADA) Prohibited List, treating physicians should
be aware of the latest WADA recommendations for thera-
peutic use exemptions (TUE) for those athletes who are
subject to antidoping regulations.70 From 1st January 2012,
only the inhaled β2-agonist terbutalin needs TUE; the other
commonly used inhaled β2-agonists salbutamol, salmeterol
and formoterol, as well as all inhaled steroids are no longer
on the prohibited list and are thus free for use.
▶ Athletes participating in open-water swimming events
where the water temperature may be cold should ensure
that they become familiar with the venue and are exposed
to the water ahead of time, and be sure that they participate
in a sufficient warm-up.
Recommendations for research
To further improve safety in cold for all participants, the panel
recommends new research to examine:
▶ Accurate measures of metabolic heat production rates dur-
ing all cold-weather sport events.
▶ Prediction modelling to estimate probable body core and
exposed skin temperature changes during all cold-weather
competitive events, so as to determine a realistic range of
ambient conditions that would provide an evidence-based
defi nition of safe and appropriate weather and water tem-
perature limits for competition.
▶ Using ingestible core temperature ‘pills’ and other telem-
etry technology to directly measure body core temperature
and other physiological changes during each cold-weather
competitive event (real or simulated).
▶ Respiratory epithelial damage and airway infl ammation
from cold air exposure that are involved in development of
BHR in winter athletes.
▶ Novel treatment options to prevent respiratory epithelial
damage from cold air exposure and promote epithelial
repair.
EFFECTS OF ALTITUDE ON HEALTH AND PERFORMANCE OF
HIGH-LEVEL ATHLETES
By conventional defi nitions of altitude (table 1), 71 most athletic
events are held at altitudes that pose little to no health risks;
yet even modest altitudes can affect performance. Decreased
barometric pressure at altitude reduces air density and the
Table 1 Characteristics of altitude ranges71
Altitude Definition
0–500 m ‘Near sea level’
Above 500–2000 m ‘Low altitude’: minor impairment of aerobic
performance becomes detectable
Above 2000–3000 m ‘Moderate altitude’: mountain sickness starts to occur
and acclimatisation is increasingly important for
performance
Above 3000–5500 m ‘High altitude’: mountain sickness and acclimatisa-
tion become clinically relevant; performance is
considerably impaired
Above 5500 m ‘Extreme altitude’: prolonged exposure leads to
progressive clinical deterioration
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partial pressure of inspired oxygen (PO2). These two fac-
tors have differential, often opposing, effects on endurance,
strength/power and skills necessary for elite level perfor-
mance. The reduction in PO2 impairs maximum aerobic capac-
ity and endurance performance in sports (eg, distance running
and cross country skiing), where little benefit is gained from
the reduction in air resistance associated with reduced air den-
sity.72 Individual decrements in performance are subject to a
high degree of sport-specific physiologic variation. For higher
velocity sports (eg, speed skating, cycling and sprinting), ben-
efits gained from reduced drag can outweigh limitations in aer-
obic capacity, resulting in improved performance.73 Maximum
strength and power (eg, weight lifting) are not affected by alti-
tude, yet repeated bouts of high-intensity efforts (eg, sprinting
in team sports) may be more affected.74 Since projectile motion
(eg, ball sports, throwing, shooting and ski jumping) is altered
by reduced air density, specific skills requiring precise timing,
accuracy and position may be adversely affected.75 The overall
effect of altitude is thus sport/event specific.
Cardiovascular and pulmonary system
During submaximal exercise, cardiac output (Q) and locomo-
tor muscle blood flow are increased, offsetting the reduction in
arterial oxygen content. During maximal (and supra-maximal)
exercise at moderate altitude, Q and locomotor muscle blood
flow will reach maximum values, which are similar to those
observed at sea level.76–78 The blood pressure response during
exercise in acute moderate hypoxia is comparable with that
observed during exercise at sea level, and consequently the
O2 demand of the heart is the same as well. However, there
is no indication of reduced myocardial contractility during
maximal exercise, even at a higher altitude.79 80 Consequently,
the cardiovascular risks incurred during exercise at moderate
altitude can be considered similar to those assumed during the
same exercise modes at sea level. The only particular differ-
ence may be represented by the few elite endurance athletes
having severe exercise-induced arterial hypoxaemia at sea
level. These athletes may develop more severe hypoxaemia at
mild altitude;81 but there is currently no evidence of increased
cardiovascular risk for elite athletes exercising at moderate
altitude. As a caution, individuals (eg, coaches and other sup-
port staff) with cardiovascular or pulmonary diseases who are
accompanying athletes travelling to moderate or high altitude
ought to seek medical advice.
Acute mountain sickness
Acute exposure of non-acclimatised individuals to moder-
ate altitude may lead to acute mountain sickness (AMS),
which is a self-limiting condition comparable with having a
‘hang-over’ or migraine attack.82 It can be treated by rest and
prevented by slow (staged) ascent or preceding exposures
(preacclimatisation).83 The prevalence of AMS is 0–25% at
moderate altitude, depending on the individual susceptibili-
ty.84 Severe obesity and pulmonary disease are additional
risk factors for AMS that may be relevant for accompanying
staff. AMS prevalence is not different between normobaric
and hypobaric hypoxia at the same ambient PO2.85 86 Living
or sleeping at moderate altitude for 8–16 h/day does not cause
discomfort attributable to hypoxia.87 Moreover, exposures
over a few minutes to 2–3 h to more severe hypoxia (equiva-
lent to 5000–6000 m above sea level) are too short to cause
AMS and are well tolerated by healthy athletes at rest and
during exercise. Life-threatening high-altitude pulmonary and
cerebral oedema rarely occur below 3000 and 4000 m above
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bjsports-2012-091296.indd 7
sea level, respectively, and only after several days of exposure,
and therefore are not concerns at altitudes where most compe-
titions are carried out.88
Preparation and other considerations for events held at low
and moderate altitudes
The key factor in reducing clinical risk and optimising per-
formance is to arrive to the site of competition or to a site of
equivalent altitude some time well ahead of the actual event.89
Arriving 2 weeks before competition at moderate altitude and
allowing 1 or 2 days of rest beore taking up regular training,
is the typical recommended approach. At moderate altitude,
most athletes will acclimatise within 2 weeks. Partial accli-
matisation leading to improved performance can be achieved
within 5–7 days, but some individuals may need more time.
For acclimatisation at lower altitudes, less time may be suf-
ficient. It is not clear whether modalities such as training in
hypoxia while living in normoxia or ‘live high and train low’
are beneficial for elite athletes competing at moderate altitude.
An acclimatisation period over about 2 weeks is also important
for sports which are affected by low-air density, as emphasised
in the segment (above) on performance.88
Nutrition
Haemoglobin concentration increases acutely with altitude
exposure because of diuresis and over time by increased eryth-
ropoiesis. At moderate altitude, the diuretic response is small
and may not be noticed. In athletes with poor-iron status,
erythropoiesis is likely to be impaired.91 Therefore, athletes
should be checked for serum ferritin about 8–10 weeks prior
to exposure to moderate altitude for training or competition.
Based on the current evidence, athletes are often advised to
increase their dietary iron intake or receive iron supplementa-
tion orally when serum ferritin values are less than 30 μg/l for
women or 40 μg/l for men.92
Hypoxia for improvement of performance near sea level
Placebo-controlled double-blind studies show that passive
exposure to hypoxia over several hours does not improve
aerobic or anaerobic performance.93–95 Whether training in
hypoxia while living in normoxia is superior to training in
normoxia for enhancing performance of elite athletes near sea
level needs to be investigated in carefully controlled double-
blind studies. Moreover, the purported performance gain by
living at simulated moderate altitude and training at low alti-
tude91 has been challenged recently.96
Recommendations for research
Specific to the effects of altitude on athlete health and perfor-
mance, the panel recommends future investigations to:
▶ Study the effects of training in hypoxia and live high, train
low modalities on performance at sea level and low and
moderate altitude using a placebo-controlled double-blind
design.
▶ Determine the effect of duration of altitude acclimatisation
on performance: how many days does it take to achieve
maximal improvement of performance at a particular
altitude?
▶ Obtain high-quality (invasive) data on the cardiovascular
response to exercise at low and moderate altitude in elite
athletes.
▶ Investigate the combination of heat, cold and competi-
tion stress on performance or AMS at low and moderate
altitude.
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INTERNATIONAL SPORT FEDERATIONS: RECOGNISING
THE RISKS
Epidemiological data from the USA show that an estimated
5946 persons were treated in US emergency departments each
year during 2001–2009 for exertional heat illness incurred
while participating in a sport or recreational activity.97
According to the Annual Survey of (American) Football Injury
Research, 132 fatalities have been documented from exertional
heatstroke from 1931 through 2009, and between two and five
cases per year in recent years.98 In cycling at the 2002 Argus
Cycle Tour in South Africa, five deaths from exertional heat-
stroke were reported.99 These data show that there is a mea-
surable risk of severe exercise/heat-related illness and injury in
certain sports. It should be noted, however, that most partici-
pants in these studies are adolescent, collegiate or recreational
athletes. Accordingly, there is limited reported evidence to
date indicating a high-exertional heat illness risk among ath-
letes during Olympic or other competitive events at the world
championship level. However, this neither confi rms a lack of
risk nor mitigates the need to comprehensively examine heat-
related challenges and provide standards to further minimise
potential exertional heat illness risk – even with these elite
international-level athletes.
Accordingly, international federations have responded to the
environmental challenges and health risks in sport. For exam-
ple, although there is no record of heat-related deaths in elite
football or beach volleyball, the Fédération Internationale de
Football Association (FIFA) and the Fédération Internationale
de Volleyball (FIVB) have established guidelines to avoid the
scheduling of matches during the hottest periods of the day to
reduce exertional heat illness risk to the players. Other mea-
sures include allowing cooling breaks (in the 2008 Olympic
Games men’s football fi nal, cooling breaks were introduced at
30 and 75 min), permitting more frequent side changes or tim-
eouts (used on the FIVB beach volleyball World Tour to allow
players to rest and rehydrate). Also, plenty of ice, cold tow-
els, cool mist spray and water/rehydration fluids are readily
available to encourage athlete cooling. Another key preven-
tive measure is systematic monitoring of the environmental
conditions. In certain sports, including marathon running and
FIFA and FIVB competitions, WBGT recordings are used to
guide decisions on implementing additional on-site measures
to improve the safety of athletes.
With cold-weather competition, winter sports federations
such as the Fédération Internationale de Ski (FIS) closely monitor
air temperature and wind, in order to make the most appropriate
recommendations on limiting cold exposure for these athletes,
so as to minimise the risk of hypothermia, frostbite and other
cold-related problems. Both the Nordic skiing events as well as
biathlon have enforced temperature limitations on organisers of
World Cup races; and many national federations have even more
all-encompassing rules and measures to limit cold exposure.
Another venue of recognised concern is with marathon
swimming, where there are unique environmental challenges
and safety concerns in the open water posed by the weather,
currents and tides, pollutants and flora and fauna. In response
to these environmental threats, FINA has instituted changes
to protect health and safety of the swimmer. For example,
low- and high-temperature limits have been added to the
rules and recommendations, respectively, to ensure that ath-
letes are not exposed to potentially dangerous extremes in
water temperatures. In addition, strict water quality protocols
and emergency procedures ensuring athlete safety have been
instituted.
Br J Sports Med 2012;46:770–779. doi:10.1136/bjsports-2012-091296
bjsports-2012-091296.indd 8
Highlight paper
While altitude appreciably increases physiological strain,
inhibits performance, and prompts a variety of clinical symp-
toms in unprepared and unacclimated individuals, elite ath-
letes rarely compete in settings higher than 2000 m above sea
level. However, myriad athletes regularly use altitude training
above this level to improve performance at low or moderate
altitude. Accordingly, guidelines and measures to improve alti-
tude acclimatisation, tolerance, and safety have been reviewed
and warrant additional attention.75
OVERALL CONSENSUS – WHAT ELSE CAN BE DONE?
While physiology and medicine have been looking after both
healthy and pathological organisms for centuries, exercise
physiology is a relatively young subdiscipline. The physiology
of the exercising human has been primarily studied from occu-
pational, military and laboratory situations. Therefore, there is
a clear need for sports federations, team doctors and research-
ers to collaborate in obtaining much more data and publish-
ing the fi ndings on the specific population of elite athlete. The
challenge is now to move from the knowledge of the ‘standard
human physiological responses’ to determining and consid-
ering the specific characteristics, responses and behaviour of
the elite athlete training and competing across the breadth of
encountered environmental extremes.
Accordingly, the panel applauds the IOC Medical Commission’s
and International Sport Federations’ demonstrated commit-
ments to athlete safety. However, we urge the Commission
and Federations leaders to assertively and openly press fur-
ther in their pursuit to better appreciate, closely monitor and
appropriately respond to the health and safety challenges in
all sport venues, so every Olympic and international-level ath-
lete is adequately protected and thus given the opportunity to
demonstrate optimal athletic performance.
Acknowledgements The group acknowledges the contribution of IOC Medical
Commission Chairperson, Arne Ljungqvist, and IOC Medical and Scientific Director,
Patrick Schamasch during the IOC Consensus Meeting.
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.
Author affiliations
1National Youth Sports Health & Safety Institute, USA;
2Department of Paediatrics, Sanford School of Medicine of The University of South
Dakota, Sanford Children’s Health Research Center, Sioux Falls, SD, USA;
3Oslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian
School of Sport Sciences, Oslo, Norway
4 Department of Internal Medicine, Division VII: Sports Medicine, University
Hospital, Heidelberg, Germany
5Institut de recherche biomedicale de defense - Ecole du Val-de-Grace (IRBA-
EVDG), Paris, France
6Department of Physical Education, University of Las Palmas de Gran Canaria, Las
Palmas de Gran Canaria, Spain
7Faculty of Medicine, University of Oslo, Oslo, Norway
8Norwegian School of Sport Sciences, Oslo, Norway
9 Department of Paediatrics, Rikshospitalet, Oslo University Hospital, Oslo, Norway
10 Centre for Sports Medicine and Human Performance, Brunel University, Uxbridge,
United Kingdom
11ZIHP and Institute of Physiology, University of Zurich, Zurich, Switzerland
12School of Sport, Exercise and Health Sciences, Loughborough University,
Loughborough, United Kingdom
13ISSUL Institute of Sport Sciences, Department of Physiology, Faculty of Biology
and Medicine, University of Lausanne, Lausanne, Switzerland
14 Medical Commission, Fédération Internationale de Natation, Lausanne,
Switzerland
15Medical Commission, International Olympic Committee, Lausanne, Switzerland
16McMaster University, Hamilton, Canada
17ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Research and
Education Centre, Doha, Qatar
18Department of Neuroscience and Pharmacology, University of Copenhagen,
Copenhagen, Denmark
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19 Medical Committee, Fédération Internationale de Football Association, Zurich,
Switzerland
20 Medical Commission, Badminton World Federation, Kuala Lumpur, Malaysia
21Medical Committee, Asian Football Confederation, Bukit Jalil, Kuala Lumpur,
Malaysia
22Department of Biology and Altitude Research Center, University of Colorado,
Colorado Springs and Anschutz Medical Campuses, USA
23Military Nutrition Division, US Army Research Institute of Environmental
Medicine, Natick, MA, USA
24 Medical & Scientific Department, International Olympic Committee, Lausanne,
Switzerland
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 Downloaded from http://bjsm.bmj.com/ on December 5, 2014 - Published by group.bmj.com

International Olympic Committee consensus

statement on thermoregulatory and altitude
challenges for high-level athletes
MF Bergeron, R Bahr, P Bärtsch, L Bourdon, JAL Calbet, KH Carlsen, O
Castagna, J González-Alonso, C Lundby, RJ Maughan, G Millet, M
Mountjoy, S Racinais, P Rasmussen, AW Subudhi, AJ Young, T Soligard
and L Engebretsen

Br J Sports Med 2012 46: 770-779 originally published online June 9,

2012
doi: 10.1136/bjsports-2012-091296

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